Basic Information
| Provider Information | |||||||||
| NPI: | 1568931772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | LOBERG | ||||||||
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| Credential: | PTA | ||||||||
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| OtherLastName: | LOBERG | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 422 S 23RD AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989022801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098340522 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3801 KERN WAY | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989026340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095743200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2018 | ||||||||
| LastUpdateDate: | 11/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 60638325 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.